Healthcare Provider Details

I. General information

NPI: 1154596286
Provider Name (Legal Business Name): SOUTHEAST ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11548 CHAPMAN HWY
SEYMOUR TN
37865
US

IV. Provider business mailing address

11548 CHAPMAN HWY
SEYMOUR TN
37865
US

V. Phone/Fax

Practice location:
  • Phone: 865-577-7800
  • Fax:
Mailing address:
  • Phone: 865-577-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE L TRACY
Title or Position: OFFICE MANAGER
Credential:
Phone: 865-977-7110